What type of organ dysfunction must be associated with severe sepsis for proper coding?

Severe sepsis is defined by the presence of a systemic inflammatory response syndrome (SIRS) along with acute organ dysfunction resulting from an infection. For proper coding, it is critical to identify acute organ dysfunction, as it indicates a sudden and severe impairment in the function of the organs, which can lead to life-threatening conditions. This acute dysfunction can manifest through signs such as altered mentation, decreased urine output, and abnormal liver function tests, among others.

In contrast, chronic organ dysfunction refers to long-standing issues that typically do not represent the immediate and severe complications associated with severe sepsis. Mild organ dysfunction does not meet the criteria for severe sepsis, as it lacks the severity required for such a diagnosis. While any organ dysfunction may be present, it is the acute nature of the dysfunction that is key for coding severe sepsis accurately. Thus, recognizing and coding acute organ dysfunction is essential for proper documentation and treatment of severely ill patients.